Use of Lipid-based Nutrient Supplements (LNS) to Improve the Nutrient Adequacy of General Food ...

138 Pages·2009·0.84 MB·English

Use of Lipid-based Nutrient Supplements (LNS) to Improve the
Nutrient Adequacy of General Food Distribution Rations for
Vulnerable Sub-groups in Emergency Settings

Prepared for the Inter-Agency Standing Committee Global Nutrition Cluster By

Camila M. Chaparro (FANTA-2 Project/AED)

and

Kathryn G. Dewey (University of California, Davis)

July 2009
This work was funded by a grant from the
IASC Global Nutrition Cluster and “in
kind” support from the Food and Nutrition

Technical Assistance II Project (FANTA-

2).

The contribution from FANTA-2 was
made possible by the generous support
of the American people through the
support of the Office of Health, Infectious
Disease, and Nutrition, Bureau for Global
Health, United States Agency for
International Development (USAID),
under terms of Cooperative Agreement
No. GHN-A-00-08-00001-00, through the
Food and Nutrition Technical Assistance
II Project (FANTA-2), managed by the
Academy for Educational Development
(AED). The contents are the
responsibility of the authors and do not
necessarily reflect the views of USAID or
the United States Government.

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Table of Contents

Executive Summary......................................................................................................................................9
1. Introduction.............................................................................................................................................12
1.1 The current nutrition response to emergencies................................................................................12
1.1.1 General food distributions.........................................................................................................13
1.1.2 Supplementary feeding programs.............................................................................................15
1.1.3 Micronutrient interventions........................................................................................................16
1.1.4 LNS as supplements in an emergency nutrition response........................................................17
2. Objectives...............................................................................................................................................19
3. Methodological approach........................................................................................................................20
3.1 Dietary intake in emergency nutrition settings and composition of rations for general food
distribution...............................................................................................................................................20
3.2 Hypothetical intake from example general food distribution rations.................................................21
3.3 Nutrient composition and adequacy of hypothetical ration...............................................................22
3.4 Determination of the desired micronutrient composition of LNS......................................................25
3.5 Accounting for bioavailability of nutrients from the general food distribution ration and LNS..........27
3.6 Cost comparability estimates............................................................................................................27
4. Results....................................................................................................................................................27
4.1 Nutrient adequacy of typical general food distribution ration............................................................27
4.1.1 Hypothetical intake from and nutrient adequacy of typical general food distribution ration for
children 6-11 months of age...............................................................................................................28
4.1.2 Hypothetical intake and nutrient adequacy of typical general food distribution ration for children
12-35 months of age..........................................................................................................................29
4.1.3 Hypothetical intake from and nutrient adequacy of typical general food distribution ration for
pregnant and lactating women...........................................................................................................30
4.2 Nutrient adequacy of revised general food distribution ration with the addition of LNS...................31
4.2.1 Age/physiological group specific approach for developing LNS formulation............................32
4.2.2 Age-specific LNS formulation for 6-35 month-old infants and children.....................................32
4.2.3 Hypothetical intake from and nutrient adequacy of revised general food distribution ration plus
age-specific LNS for 6-35 month-old children....................................................................................35
4.2.4 Age-specific LNS formulation for pregnant and lactating women.............................................35
4.2.5 Hypothetical intake from and nutrient adequacy of revised general food distribution ration plus
age-specific LNS for pregnant and lactating women..........................................................................37
4.3 One-size-fits-all approach for developing LNS formulation..............................................................37
5. Appropriate use and toxicity concerns....................................................................................................39
5.1 Potential strategies to ensure appropriate use and avoid inappropriate consumption.....................43
6. Cost estimates of providing LNS with the revised general food distribution ration.................................45
7. Quality control, nutrient formulation, shelf-life and packaging................................................................47
7.1 Quality control of LNS production.....................................................................................................48
7.2 Nutrient formulation..........................................................................................................................48
7.3 Shelf-life and packaging...................................................................................................................49
8. Discussion...............................................................................................................................................50
Acknowledgments.......................................................................................................................................54
Appendices.................................................................................................................................................58
Appendix 1: Food ration examples used for development of typical general food distribution ration
(Tables A1.1 to A1.7)..............................................................................................................................59
Appendix 2: Nutrient composition of principal food aid commodities used in this document.................61
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Appendix 3: Protein adequacy of diets in emergency settings when supplemented with lipid-based
nutrient supplements (Tables A3.1 to A3.7)...........................................................................................64

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List of Tables

Table 1: “Typical” GFD ration with CSB, and a “revised” GFD ration with CSB substituted with an
equivalent amount of pulse and grain.........................................................................................................72
Table 2: Energy requirements of each age/physiologic group...................................................................73
Table 3: Hypothetical intake for each age/physiological group from the “typical” GFD ration...................74
Table 4: Hypothetical intake for each age/physiological group from the “revised” GFD ration, adjusted for
the quantity of LNS that will be added (118 kcal).......................................................................................75
Table 5: Average nutrient concentrations in mature breast milk................................................................76
Table 6: Adequate Intakes (AI) and Recommended Nutrient Intakes (RNIs) and Upper Limits (UL) for 7-
11 month-old infants (Institute of Medicine and WHO/FAO 2004)..............................................................77
Table 7: Adequate Intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient
Intakes (RNIs) and Upper Limits (UL) for 1-3 year-old (12-35 month-old) children (Institute of Medicine
and WHO/FAO 2004)..................................................................................................................................79
Table 8: Adequate intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient
Intakes (RNIs) and Upper Limits (UL) for pregnant women (19+ years of age) (Institute of Medicine and
WHO/FAO 2004).........................................................................................................................................81
Table 9: Adequate intakes (AI), Recommended Dietary Allowances (RDAs) or Recommended Nutrient
Intakes (RNIs) and Upper Limits (UL) for lactating women (19+ years of age) (Institute of Medicine and
WHO/FAO 2004).........................................................................................................................................83
Table 10: Hypothetical quantity consumed from each component of “typical” GFD diet, all age/physiologic
groups.........................................................................................................................................................85
Table 11: Amount of nutrient provided by each “typical” GFD diet (and “average” breast milk intake) and
percent of the daily recommended intake provided for 6-8 month-old children..........................................86
Table 12: Amount of nutrient provided by each “typical” GFD diet (and “average” breast milk intake) and
percent of the daily recommended intake provided for 9-11 month-old children........................................88
Table 13: Amount of nutrient provided by each “typical” GFD diet (and “average” breast milk intake) and
percent of the daily recommended intake provided for 12-23 month-old children......................................90
Table 14: Amount of nutrient provided by each “typical” GFD diet and percent of the daily recommended
intake provided for 24-35 month-old children..............................................................................................92
Table 15: Nutrients that exceed the UL from the hypothetical intake from the “typical” GFD ration..........94
Table 16: Amount of nutrient provided by each “typical” GFD diet and percent of the daily recommended
intake provided for pregnant women...........................................................................................................95
Table 17: Amount of nutrient provided by each “typical” GFD diet and percent of the daily recommended
intake provided for lactating women...........................................................................................................97
Table 18: Composition (g) of hypothetical intakes from “revised” GFD diet, taking into account energy
content (118 kcal or 236 kcal) to be provided via LNS...............................................................................99
Table 19: LNS macro- and micro-nutrient content for 6-35 month-olds based on the higher of the two
daily recommended intake values for 7-11 and 12-35 months.................................................................100
Table 20: Amount of nutrient provided by each “revised” GFD diet, breast milk and LNS (6-35 mo
formulation) and percent of the daily recommended intake provided for 6-8 month-old children.............102
Table 21: Amount of nutrient provided by each “revised” GFD diet, breastmilk and LNS (6-35 mo
formulation) and percent of the daily recommended intake provided for 9-11 month-old children...........104
Table 22: Amount of nutrient provided by each “revised” GFD diet, breastmilk and LNS (6-35 mo
formulation) and and percent of the daily recommended intake provided for 12-23 month-old children..106
Table 23: Amount of nutrient provided by each “revised” GFD diet, breastmilk and LNS (6-35 mo
formulation) and percent of the daily recommended intake provided for 24-35 month-old children.........108
Table 24: Nutrients that exceed the UL when the 6-35 mo formulation LNS is added to the hypothetical
intake from the GFD ration, and breast milk (when applicable)................................................................110
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Table 25: LNS macro- and micro-nutrient content for pregnant and lactating women (PLW) based on the
higher of the two RNI levels for pregnancy and lactation.........................................................................111
Table 26: Amount of nutrient provided by each “revised” GFD diet and LNS (PLW formulation) and
percent of the daily recommended intake provided for pregnant women.................................................113
Table 27: Amount of nutrient provided by each “revised” GFD diet and LNS (PLW formulation) and
percent of the daily recommended intake provided for lactating women..................................................115
Table 28: Nutrients that exceed the UL when the PLW LNS formulation is added to the hypothetical
intake from the GFD ration........................................................................................................................117
Table 29: LNS micronutrient content for all groups, “one-size fits all” approach.....................................118
Table 30: Amount of nutrient provided by each “revised” GFD diet and LNS (“one size” formulation) and
percent of the daily recommended intake provided for pregnant women.................................................119
Table 31: Amount of nutrient provided by each “revised” GFD diet and LNS (“one size” formulation) and
percent of the daily recommended intake provided for lactating women..................................................121
Table 32: Nutrients that exceed the UL when the “one-size” LNS formulation is added to the hypothetical
intake from the GFD ration........................................................................................................................123
Table 33: Toxicity estimates for 6-35 month-old children consuming 2-7 times the recommended daily
dose of the age-specific or one-size LNS formulation (alone)..................................................................124
Table 34: Toxicity estimates for 6-35 month-old children consuming 2-7 times the recommended daily
dose of the PLW LNS formulation (alone)................................................................................................125
Table 35: Toxicity estimates for PLW consuming 2-7 times the recommended daily dose of the PLW LNS
formulation (alone)....................................................................................................................................126
Table 36: Toxicity estimates for PLW consuming 2-7 times the recommended daily dose of LNS (alone),
for the one-size formulation.......................................................................................................................127
Table 37: Average commodity cost in US$ per metric ton (MT) of GFD commodities............................128
Table 38: Cost estimate (in US$) for “typical” full GFD ration and “revised” full GFD ration (excluding
sugar and salt)..........................................................................................................................................129
Table 39: Cost (in US$) of providing the hypothetical diet for each age/physiologic group from the
“typical” and “revised” GFD rations, with and without addition of LNS, as well as the percent change in
cost from the current “typical” GFD ration.................................................................................................130
Table 40: Change in total commodity provided for the “typical” GFD diet vs. “revised” GFD diet plus LNS
for each age/physiologic group, plus a hypothetical mother-child dyad...................................................131
Table 41: Possible chemical forms of nutrients included in products for infants and young children, and
recommended chemical forms for inclusion in LNS..................................................................................132

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List of Figures

Figure 1: Percent of the daily recommended intake provided by the “typical” GFD ration (and “average”
breast milk intake) for selected nutrients for 6-8 month-old infants..........................................................134
Figure 2: Percent of the daily recommended intake provided by the “typical” GFD ration (and “average”
breast milk intake) for selected nutrients for 9-11 month-old infants........................................................134
Figure 3: Percent of the daily recommended intake provided by the “typical” GFD ration (and “average”
breast milk intake) for selected nutrients for 12-23 month-old infants......................................................135
Figure 4: Percent of the daily recommended intake provided by the “typical” GFD ration (and “average”
breast milk intake) for selected nutrients for 24-35 month-old infants......................................................135
Figure 5: Percent of the daily recommended intake provided by the “typical” GFD ration for selected
nutrients for pregnant women...................................................................................................................136
Figure 6: Percent of the daily recommended intake provided by the “typical” GFD ration for selected
nutrients for lactating women....................................................................................................................136
Figure 7: Percent of the daily recommended intake provided by the “typical” GFD ration for selected
nutrients for a 4-year old child...................................................................................................................137
Figure 8: Percent of the daily recommended intake provided by the “revised” GFD ration for selected
nutrients for a 4-year old child...................................................................................................................137
Figure 9: Percent of the daily recommended intake provided by the “typical” GFD ration for selected
nutrients for an adult male.........................................................................................................................138
Figure 10: Percent of the daily recommended intake provided by the “revised” GFD ration for selected
nutrients for an adult male.........................................................................................................................138

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List of Acronyms
AI Adequate intake
AMDR Acceptable macronutrient distribution range
CSB Corn soy blend
CV Coefficient of variation
EAR Estimated average requirement
EFA Essential fatty acid
EMOP Emergency operation
FAO Food and Agriculture Organization
FBF Fortified blended food
GFD General food distribution
IDP Internally-displaced person
IOM Institute of Medicine
IZiNCG International Zinc Nutrition Consultative Group
LNS Lipid-based nutrient supplement
MAM Moderate acute malnutrition
MNP Micronutrient powder
NOAEL No observed adverse effect level
PLW Pregnant and lactating women
RDA Recommended dietary allowance
RNI Recommended nutrient intake
RUTF Ready-to-use therapeutic food
SAM Severe acute malnutrition
SFP Supplementary (selective) feeding program
UL Upper Level
USDA United States Department of Agriculture
USAID United States Agency for International Development
WFP World Food Program
WHO World Health Organization
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Executive Summary
The term “lipid-based nutrient supplements” (LNS) refers generically to a range of fortified, lipid-
based products, including products like Ready-to-Use-Therapeutic Foods (RUTF) (a large daily ration with
relatively low micronutrient concentration) as well as highly-concentrated supplements (1-4
teaspoons/day, providing < 100 kcal/day) to be used for “point-of-use” fortification. RUTF have been
successfully used for the management of severe acute malnutrition (SAM) among children in emergency
settings. Recent research on smaller doses of LNS for prevention of malnutrition has created interest in
their potential use in emergency settings to ensure a more nutritionally-adequate ration for the most
vulnerable groups (e.g., infants and children between 6 and 24 months of age, and pregnant and lactating
women (PLW)). Currently, the main food and nutrition interventions in emergency settings include general
food distribution (GFD) rations, which are provided to the affected population as a whole, and selective
(or supplementary) feeding programs (SFP), which are to be provided to nutritionally-vulnerable or
malnourished individuals. In addition to logistical and operational challenges that may limit the intended
effect of these programs, the nutritional quality of the food commodities provided may be insufficient to
meet the needs of infants and young children and PLW. Because these sub-groups have particularly high
nutrient needs for growth and development, meeting these needs is challenging in settings where the
ration is limited to a few food commodities, with little access to a diverse diet and bioavailable sources of
micronutrients. In recent years there has been increased attention to adding micronutrient interventions,
on top of the other food-based interventions (such as GFDs and SFPs), to fill micronutrient gaps in diets
in emergency settings.
The focus of this document is the potential role of LNS in meeting the nutritional needs of these
vulnerable sub-groups, with the goal of preventing malnutrition in emergency-affected populations. The
document addresses the desired nutritional formulation of LNS for these target groups, taking into
account the expected bioavailability of relevant nutrients and toxicity concerns. It also discusses the
recommended chemical forms of the fortificants in LNS; stability and shelf life considerations; production,
packaging and distribution of LNS in the context of emergencies; and cost implications of the addition of
LNS to current GFD rations for vulnerable groups.
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To develop the desired nutritional formulation of LNS for these purposes, we calculated the
current nutrient content of commonly provided GFD rations and determined the nutritional “gaps” (of both
micro- and macro-nutrients) of these rations for each of the target groups (i.e., children 6-35 months of
age and PLW). For fat and protein, both quantity and quality were evaluated. Through an iterative
process, we determined the formulation of a small dose of LNS that would best meet the recommended
nutrient intakes for each group in combination with other foods in the GFD ration (composed of a grain,
pulse, oil, sugar and salt, but excluding a fortified blended food (FBF)), as well as breast milk for children
6-24 months of age, while avoiding excess levels of any one nutrient to the extent possible. The
composition of the LNS used for these calculations is based on an existing LNS product (Nutributter®,
Nutriset), but with less sugar and more oil. Two different approaches were used: 1) developing two
different formulations of LNS, one to be used for infants and children 6-35 months of age and a separate
one for PLW, and 2) developing a single formulation that could be used for all of these subgroups. We
used commodity cost data to estimate the cost of adding an LNS product to the GFD ration.
The results indicate that the typical GFD ration currently provided in emergency settings—based
on cereals, pulse, a FBF such as corn-soy blend (CSB), oil, salt and sugar—does not meet the nutritional
needs of infants and young children and PLW. The hypothetical intake from a ration composed of food aid
commodities (based on the current USAID/USDA specifications for exported food aid commodities used
in emergency settings), and including breast milk for children 6-24 months of age, provided less than 75%
of the recommended intake for several micronutrients for certain age/physiologic groups, including
calcium, iron, zinc, B vitamins such as riboflavin, B6 and B12, and fat-soluble vitamins such as D, E and
K. It also generally contained lower than recommended levels of fat and essential fatty acids.
The initial LNS formulation for each target group was designed to provide 100% of the
recommended amount (RDA or RNI) for most micronutrients per daily dose (20 g, ~118 kcal) of LNS. This
would ensure consumption of the recommended levels of each nutrient even if the “base” diet changed.
However, since such a formulation could provide excess amounts of certain nutrients when consumed in
combination with the “base” diet (especially when the “base” diet contains fortified foods), we made
adjustments in the LNS formulation when there was a risk of greatly exceeding the Upper Level for
certain sub-groups and there were relevant concerns about adverse effects from chronic consumption of
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